Factors affecting shoulder mobility in open and arthroscopic surgery for anterior traumatic instability

J. Shoulder Elbow Surg. Volume 4, Number 1, Part 2

73

74

Abstracts

SURGICAL TREATMENT OF FRESH ACROMIOCLAVICULAR JOINT DISLOCATIONS : SUTURE OR NO SUTURE OF THE CORACOCI,AV1CULAR L I G A M E N T S ? F. Picard, E. M o n t h a r b o ~ Y. T o u r n t , J.M. Leroy, D. Saragaglla Service de Chirurgie O r t h o p t d | q u e et de T r a u m a t o l o # e du Sport - C.H.U. de Grenoble - Hbpital Sud - FRANCE. The goal of this prospective study was to show the interest of acute acromio-clavicular joint dislocation (ACD) stabilization without suture of coraco. clavicular ligaments. 30 patiems were operated on between 1990 and 1993. There were 27 males and 3 females and the average Age was 30,6 years old (18-51). 16 were manual workers, 12 were sedentar7 and 2 without prof~sional activity. 28 were sportsmen either at competition level (6 cases) or at recreational level (22 cases). All the patients were operated on before the fifteenth post-traumatic day and the average delay was of 2,5 days (0-15). According to Julliard and Bezes classification, 26 were type Ill and 4 type 1I. The surgical procedure was in these cases a pinning and shroud without coraco-clavicular ligaments suture. The eomplications were as follow : 6 pins migration includins 2 ACD recurrences. 11 patients had hypersensitivity at their scar. All the patients were reviewed functionally using the Constant's score and radiologically. We have measured the inter-coraeo-clavicular and the inter-acroruioclavicular gaps according to Weber X-Rays ; we also noted the tax'settee of subetavicular calcifications, osteolysis and acromio-clavicular arthrosis. The awwage follow up was 18,8 mozlths (6-39). The average Constant's score was of 89,97 points (pain : t3,7/15, daily activity : t9,2/20, range of motion : 40/40, strength : 14,3/25 in the operated side and 14,9 in the controlateral one). With regard to the radiological results, the average acroimo-clavicular space increasing was of 2,5rrnn and of 3,7rnm for the coracoclavicular space in comparison with the controlateral shoulder. Coracoclavicular calcifications were noted in 9 cases, clavicular t~colysis in 3 cases. and acromio-clavienlar arthrosis in 2 cases. 12 patients had "n~wmal" X-ra3~. This study concludes to clirfical soquellae absence for the procedure without coracoclavicular ligaments suture. A small acrornioclavicular distance is the witnes.s of the coracoclavicular ligaments healing. The reduction of ACD stabilized with a shixmd and pin draws near the stump ligaments, the spontaneous healing of which is stimulated by' an excellent vascularisafion. In this procedure the deltop~-toral approach is not neces~ry. For thoso who support the ACD surgical treatment, the authors think that the coraco-clavicular ligaments suture is not usofull. A comparative, consecutive and randomized study should cordlrm this opinion.

75

FACTORS AFFECTING SHOULDER MOBILITY IN OPEN AND ARTHROSCOPIC SURGERY F O R ANTERIOR TRAUMATIC INSTABlUTY. M. Rendelli, P.L Gambrioli, F. Curti latituto Ortopedico G.Pini - Milan (Italy) Many patients treated for anterior traumatic instability of the shoulder need stability but also a good recovery of mobility, mainly in abduction~and external rotation of the arm. T h e postoperative lack of mbbility is difficult to predict , because it depends on several factors. We reviewed patients with anterior .traumatic instability , treated with open or arthroscopic stabilization by the same surgical team. The series consists of 30 Bristow - Latarjet operations , 12 Jobe's capsulo-labral reconstructions, 29 arthroscopic Morgan's stabilizations and 23 Caspari's capsular repairs with multiple sutures. The Latarjet-Bristow operation showed the highest degree of external rotation limitation ( from 10 ° to 25 ° ) both with the arm at the side and abducted. Tha average lack of external rotation in Jobe's operation, treating separately capsule and subscapularis tendon, was less than in Latarjet's operation (from 5 ° to 15°). Our indication of Morgan's artroscopic repair was restricted to atients with a Bankart's lesion without disruption of the bruin. The limited retensioning of the ligamentous-labral complex allow us to obtain a good conservation of the shoulder mobility (lack of external rotation from 0 ° to 10°). On the contrary the Caspari's arthroscopic capsular repair, utilised in patients with disrupted labrum and torn ligaments, showed an higher degree of external rotation restriction in some cases of extensive capsular retensioning (from 5 ° to 15°). The separate treatment of capsule and subscapularis tendon , the ligaments' suture and the post-operative immobilisation with the arm in neutral or in slight external rotation can ameliorate the recovery of the mobility. The severity of the capsulo-labral damage and the modality of repair are the main causes of postoperative lack of ROM.

76

$35

I S O L A T E D T E A R S O F T H E S U B S C A P U L A R I S TENDON. C Gerber MD & A. Farron, MD, Dept of Otthopandins, H6pital Cantonal, Fribourg, Switzerland Until recently, isolated posttranmatie tears of the subscapularis tendon were poorly recognized. After having established the criteria for the clinical diagnosis and the diagnostic features using various imaging mndalities (JBJS 73- B: 389 - 394, 1991 ), it is the purpose of this report to review the resuRs o f surgical treatment of a consecutive series of 16 cases after a minimum follow - up of 24 (mean 43, range 24 - 84) months. MATERIAL AND METHODS 16 men with an average age of 48 years (range 27 - 59) were operated on for a complete, isolated rupture of the subscapularis tendon. A relevant trauma was at the origin in all eases. All patients had diurnal and nocturnal pain. Passive external glenohumeral rotation was increased and the strength of internal rotation was decreased in all cases, the "lift - offtest" was also positive in all cases. Surgical repair was carried out through a deltopectoral approach at an average of 15 months after trauma (1 - 56 months). All patients were reviewed clinically and radiologically. Subjective satisfaction (patients rating their shoulder as 0 - 100% of normal), working ability, scores in the simple shoulder test and on the Constant scale as well as conventional radiological parameters were assessed. RESULTS: The patients estimated their operated shoulder to be 82% of nocmal (range 20 to 100%). The age and gender adjusted Constant score was 83% (29 - 109%). The working capacity in the original profession was improved from 62% (0 - 100%) preoperatively to 96% postoperatively (one patient 50% all others 100°/6). Flexion and abducfion were within 10 degrees of the eontralateral healthy side in 16 of 17 cases, one patient had flexion of only g0 degrees. External rotation was symmetrical in 9 cases and there war a deficit of 10 degrees or less in the other 7 cases. The lift offtest war normalized in 10 cases, renlained abnormal in 6. Radiologieally there was no cranial migration of the humeral head and no significant glenohumeral arthrosis. The age of the patient, the degree of work incapacity at the time of oparation, the postoperative follow up and a concomitant lesion oftbe long head of the biceps did not influence the final outcome. Conversely, the delay between trauma and operation was inversely proportional to the quality of the result. c O N C L U S I O N : Posttraumatie, isolated, complete rupture of the subscapularis tendon accounts for 8% of the surgically treated complete rotator eufftears in the senior author's practice. It may be distinctly more frequent than previously thought, The review of the first sixteen consecutive, surgically treated cases showed satisfactory outcome. It could be statistically documented tha, the outcomeis the better, the earlier the repair is performed. In the working age group the surgical treatment war economically sound.

ARTHROSCOPIC TRANSOLENOID BANKART SUTURE REPAIR FOR TRUE ANTERIOR RECURRENT DISLOCATION OF THE SHOULDER: LONG TERM RESULTS OF 59 CASES. BUREAU P.*,WALCH G.**A..EVIGNE C"h.**,MANDRINO A.**,NEYRET Ph.** * Centre HospRulo-Univenitaire - Htpital St-Roch. 06000 Nice FRANCE. **ce~u¢ Hospitato-U nive~itaire - H6pital Lyon Sud. 69310 Pien'e B~aite FRANCE. 1"11¢pazpose of this Italy" is to repot1 our e x ~ n o c with the mahrnscopic wansglenoid mmerc t~air, as descrihod by Morgan, for the Bankart lemon following true anteri~ recurrent shoulder dislocation, Tbe results of 59 asthrnsonpic transglenoid suture repairs, parfotmed as treatment for anterior rectzrrent dislocation of the shoulder, were reviewed after an average of 4 years lind 8 months(range,twenty-nlnem seventy-onemonth).There were37 men and 22 womenwith an average age of 25,4 years (range, 15 to 55 yems). Patients were excluded if instsbiliW was volumm7 or mulndiee~o~d, although 8 patientshads positivesulcar sign.All the pademshad an average of 5.1 rsu¢ anterior recurrent dislocations of the shoulder (range, 2 m 30) and 40% of them had sorm additive subioxadons. All the procedures were performedby the sameseniorsurgeon(G.W.) or underhis control. In 28 earns we found a true Bankart lesion with an intact LGH/(Adolfsson type A); in 8 cases there were a Bankat~ lesion with a raptured LGHI (Adolfsson type B) and in 17 cases there were a combination of Bankart lesion and attenuated ruptured lahrum LGHI complex (Adolfsann type (2). In only one case we didn't found any Bankart lesion and in 6 cases the charts to imprecise to be intezpreted. There we~ 4 SLAP lesions that were dehrided or reseered. The surgical technic respected the principles described by Morgan: care was taken to abrade the glanoid rim and anterior scapular neck on the entire length of the Bankart lesion and to reconstruct a correct labrum.LGHI complex. An average of 2 sutures (range. one to seven ) were tiedundertension posteriorly after the Iransgleonid passage and with all traction removed frum the arts. All the patients were immobilized in a sling for 4 weeks. Retain to contact and overhead sportswereauthorized after 6 month. There were no complications related to the surgery itself bat two patients had a capauintis that need about ooc year to recover. Clinical evaluation, using the Duplay functional grading system, showed 33% of excellent, 9% of good, 9% of fair and 49% of poor results. Twenty-nlne patients(49%) had a failure of the repair:. 26 with recurrent anterior dislocations and 3 with subluxations. The average time to failure was 12 months, with a range of 4 to 57 months, but half of the faimres were observed after one year. Nine patients kept a positive apprehension test. and only 21 eases ( 33.8% ) estimated their result as perfect concernig stability.Twenty patients were reoparated with a Latarjet.Bristow procedure while the others didn't want any reoprration. Only 30% of the patients returned to their previous level of activity. Among the patients that didn't have recurrence, 27 had no pain and 6 had some occasional pain. All the patients, regain a complete mobility, excepted for 3 patients that had lost more than 10 degrees of extremai rotation. The only factor associated with recurrence was muhidirectional instability (6 recur~nces among 8 cases). Even if we exclude these patients, we still have a very high failure rate of 43.3%. Failures were not associated with age. sex. shoulder dominance, immobilization, numberof sutures, contact sports or surgical experience. We speculate that part of the reason for our high failure is our surgical inability to address under arthroscopy the plastic defomxation that occurs in the gleno humeral ligament labium complex after recurrent anterior dislocation. . in our exparience~ the objective results after the arthroscepiy transglent~id Bank_art suture